Tying of knots is essential in any kind of surgery. It is relatively easy in open surgery, but is difficult in laparoscopic surgery. The current art of laparoscopic knot tying employs either the extra-corporeal method, involving tying the knot by hand outside the body and pushing the knot inside with a knot pusher, or the intra-corporeal method, involving manipulation of the suture with the tips of two laparoscopic graspers, which is cumbersome, and requires considerable skill. Laparoscopic clip appliers, staplers, pre-tied knots and the like are useful substitutes, but cannot totally replace tied knots. Despite considerable prior art, there still is no hand operated instrument that renders laparoscopic intra-corporeal knot tying easier and faster.
In order to describe the tying process, the different parts of the suture ligature need to be given names. As shown in FIG. 59 in the drawings, after the suture ligature has passed around the tissue to be tied, it then presents with a head end (1), a tail end (2), a leading strand (3) and a tail strand (4),
There are two basic methods of tying a knot, whether done openly or laparoscopically. One method is making a “throw” which involves passing the head end of the suture around its tail strand. This is quite simple when performed with the fingers as in tying shoe laces. It does however involve a critical step which is the passing or release and re-grab of the head end of the suture, and wrapping it around the tail strand. In laparoscopic surgery this is difficult because the graspers are trapped in the abdominal wall, and the surgeon is limited to using only two laparoscopic graspers, one in each hand. Hence the reason for the present invention.
The second method of tying a knot involves making a loop or loops, which is commonly performed in open surgery by the surgeon making “instrument ties”, where he uses a needle holder and wraps the suture several times around it. This can be done laparoscopically but is generally difficult. There are many patents in the prior art that try to make the loop laparoscopically, but none has been commercially successful, and this is not the object of the present invention.
the present invention makes the knot differently and automatically without making the loop, or making the pass. Additionally it ties a knot in a free strand of suture ligature, without having one end of the suture being pre-fixed on to a disc or cartridge. It is therefore different in design and technique compared with other previous similar inventions.
Referring to the prior art, the Christoudias Double Grasper has 3 jaws, with a common middle jaw, and functions as a tissue approximator. Its spring loaded actuators are operated by two push buttons. The Ferzli Double Grasper, has a second pair of jaws positioned more proximally on the main shaft, whose purpose is to anchor one end of the suture prior to twisting it around the shaft of the instrument in order to produce a loop. The Hasson Suture Tying Forceps, is similar to the Ferzli, with 3 finger loops. The orthopedic suture passers are for passing sutures only through hard tissue, and these include the Arthrex Scorpion Suture Passer, and the Arthrex Birdbeak Suture Passer. Some suture passers are for passing sutures through a thickness of soft tissue such as the abdominal wall, and these include the Goretex and the Aesculap. There are devices which “pass the suture-needle” side to side, for inserting sutures into tissues, as well as for tying knots, e.g. the Autosuture's Endo-stitch, and the Japanese Maniceps. Note these only pass the suture needle, not the suture thread per se. There have been devices that attempt to “automatically” tie a knot, such as Jerrigan's experimental rotating slotted disc designed for robotic endo-cardiac surgery, but it was abandoned because of the requirement for a cartridge. There have been many devices that help to “create a loop”, with each functioning differently—(a) Kitano's grasper with the rotating sleeve, Japanese, (b) Donald Murphy's grasper with the extra horn, Australian, (c) Grice's sleeve catching instrument, (d) Bagnato & Wilson's device which simulates the radiological pig-tail catheter, with a preformed loop built into the tip of the catheter, which is deformable and purportedly a loop former, but it is difficult to manufacture and apply, and has not yet been reduced to practice, (e) Ferzli's double grasper, which anchors one end of the suture, as described above. There have been devices using a “pre-formed knot”, (1) Ethicon's Endo-Loop, (2) the Duraknot, (3) LSI's device, (4) Pare's pre-tied knot, all of which do not help to tie knots.
Past inventions related to intra-corporeal laparoscopic knot tying fail to address the basic problem of “how to make the throw”. They usually offer various alternatives, such as making multiple loops, similar to fishing knots, using pre-tied knots, knot pushers, suture clips, cinchers, tissue fasteners, anchors, stapling devices, etc. The present invention however will assist in manual intra-corporeal knot tying, and will help to produce the knot automatically.
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